Nokea
A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
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A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
You are the chair person for the healthcare facility's newly formed multidisciplinary Safety Committee. During the Forming stage of this group's development major conflicts have arisen. Which technique of conflict resolution should you use to resolve these conflicts?
- A. Passivity
- B. Compromise
- C. Competition
- D. Accommodating Others
Correct Answer: B
Rationale: During the Forming stage, where group members are establishing relationships, compromise is the most effective conflict resolution technique to promote collaboration and consensus while addressing conflicts constructively.
Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client?
- A. Albumin: 40 g/L
- B. Amylase: 40 U/L
- C. Direct bilirubin: 17 umol/L
- D. Total bilirubin: 17 umol/L
Correct Answer: D
Rationale: Total bilirubin of 17 umol/L (1 mg/dL) is elevated (normal 0.1-1.0 mg/dL), indicating potential liver or biliary issues, requiring reporting.
The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed?
- A. Uses the bell of the stethoscope
- B. Asks the client to sit straight up
- C. Places the stethoscope directly on the client's skin
- D. Encourages the client to breathe slowly and deeply through the mouth
Correct Answer: A
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.
A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
- A. Instill the eyedrops whenever the eyes feel irritated
- B. The medication may cause some transient eye discomfort
- C. Keep the medication refrigerated between doses
- D. The need to use the eyedrops will be reevaluated after 1 month
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.